Healthcare Provider Details

I. General information

NPI: 1700078714
Provider Name (Legal Business Name): SUBURBAN VISION CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6828 MARKET ST
BOARDMAN OH
44512-4503
US

IV. Provider business mailing address

6828 MARKET ST
BOARDMAN OH
44512-4503
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-9870
  • Fax: 330-629-9791
Mailing address:
  • Phone: 330-629-9870
  • Fax: 330-629-9791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3497 / T1403
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number152W00000X
License Number StateOH

VIII. Authorized Official

Name: DR. CHRISTOPHER W. SHOEMAKER
Title or Position: PRESIDENT
Credential: OD
Phone: 330-629-9870